Beech House

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Lincolnshire Community Health Services NHS Trust (LCHS) GP out-of-hours service on 2, 3, 4 and 17 August 2016. The overall rating for the service was inadequate. The service was rated as inadequate for being safe and well led, requires improvement for being effective and responsive and good for being caring.

The full comprehensive report from the August 2016 inspection can be found by selecting the ‘all reports’ link for ‘Beech House’ on our website at www.cqc.org.uk.

Where a service is rated as inadequate for one of the five key questions, it has to be inspected within six months of the publication of the original inspection report. We informed LCHS that we intended to carry out a full comprehensive inspection which would consist of unannounced inspections of primary care centres and an announced visit to the Trust headquarters ‘Beech House’.

We carried out a combination of announced and unannounced visits as part of a full comprehensive inspection of LCHS GP out-of-hours service in August and September 2017.

We carried out an unannounced visit of Boston, Grantham, Lincoln and Louth primary care centres on 25 and 26 August 2017. We carried out an announced visit to the Trust headquarters located at Beech House, Lincoln on 30 and 31 August 2017 and unannounced visits to Skegness primary care centre on 6 September 2017 and a further visit to Lincoln primary care centre on 7 September 2017. We then carried out an announced visit to Beech House on 22 September 2017. Overall the service is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for recording, reporting and learning from significant events.
• Risks to patients were assessed and well managed. With the exception of those in relation to concerns found at Lincoln primary care centre.
• Patients’ care needs were assessed and delivered in a timely way according to need. The service met the National Quality Requirements with the exception of NQR12 (performance standard in respect of the time taken to commence face to face consultations in both primary care centres and in people’s homes). Performance results had improved since our last inspection. We looked at an audit of breaches in relation to NQR12 carried out by the Trust. Findings showed that 92% of cases had an incorrect priority assigned and 30% of cases could have been managed with alternative dispositions such as clinical advice and referral to other services. Based on this data, the Trust could have achieved 93% performance for NQR12 compared to the actual reported achievement of 57% in August.
• The Trust had systems in place to engage with staff and obtain their views about the out- of-hours service.
• The Trust had a ‘green card’ system in place which involved palliative care patients being issued with a dedicated telephone number to enable themselves or their carers to access the out-of-hours service via their clinical assessment service (CAS) directly, therefore removing the need to call NHS111.
• The Trust worked proactively with other organisations and with the local community to develop services that supported hospital admission avoidance and improved the patient experience. For example, the Trust worked in collaboration with Lincolnshire Integrated Voluntary Emergency Service (LIVES) first responders who are a voluntary charity and provide vital immediate care before handing over to the ambulance service when they arrive. CAS clinicians were able to dispatch LIVES responders to provide a clinical response to unscheduled calls and provide an agreed level of care such as undertaking a patient assessment including basic observations.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• There was a system in place that enabled staff access to patient records, and the out-of-hours staff provided other services, for example the local GP and hospital, with information following contact with patients as was appropriate.
• Patients experienced a service that was delivered by dedicated, knowledgeable and caring staff. They were positive about their interactions with staff and said they were treated with compassion, dignity and respect.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The primary care centres had good facilities and were well equipped to treat patients and meet their needs with the exception of Lincoln primary care centre. The vehicles used for home visits were clean and well equipped.
• There was a clear leadership structure and staff felt supported by management. The service proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Ensure care and treatment is provided in a safe way to patients.

• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

The areas where the provider should make improvement are:

• Improve signage to the out-of-hours service at primary care centres.

• Review the risk register to ensure clear information on the risk or the actual impact or mitigating actions is recorded and agreed actions or specified timescales are recorded on the risk register.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Lincolnshire Community Health Services NHS Trust (LCHS) GP out-of-hours service on 2, 3, 4 and 17 August 2016.

Overall the out-of-hours service is rated as ‘Inadequate’. Specifically, we found the  service as ‘inadequate’ for providing safe and well-led services. It was ‘requires improvement’ for providing effective and responsive services. It was good in providing a caring service. Our key findings across all the areas we inspected were as follows:

Our key findings were as follows:

• There was no effective process in place to ensure that staff and GPs received updates on NICE guidance and safety alerts such as those issued by the Medicines and Healthcare Products Regulatory Agency and Central Alerting System.

• The trust had no oversight of safeguarding referrals made by GPs working in the out-of-hours service to ensure that referrals had been tracked and effectively followed up.

• Not all staff that undertook chaperoning duties had received appropriate training.

• Although employed staff underwent a thorough recruitment and induction process to help ensure their suitability to work in this type of healthcare environment, the process for inducting sessional GPs did not provide similar assurance.

• There was insufficient assurance to demonstrate people received effective, timely care and treatment, for example in respect of the time to commence face to face consultations at both patients place of residence and primary care centres.

• The trust had failed to react in an appropriate and timely manner to concerns raised through infection prevention and control audits.

• There were systems in place to help ensure patient safety through learning from incidents and complaints about the service.

• Patients experienced a service that was delivered by dedicated, knowledgeable and caring staff. They were positive about their interactions with staff and said they were treated with compassion and dignity.

• The primary care centres where patients received care and treatment were equipped to meet the needs of patients. At one primary care centre we found that GPs used their own equipment although equipment was provided by the trust. There was no assurance that the GPs own equipment was safe and fit for purpose.

• Signage to direct patients to some out-of-hours locations were deficient or absent altogether.

• The trust had systems in place to engage with staff and obtain their views about the service and the trust.

• Although members of staff expressed positive views of the leadership at a local level and generally felt supported by them, some felt isolated and told us that the quality of service had deteriorated.

• Some GPs working in out- of- hours told us that they received little support from some senior members of the management team.

• Staff were unsure about whether they should comfort call patients who were waiting for home visits.

• The trust worked proactively with other organisations and with the local community to develop services that supported hospital admission avoidance and improved the patient experience.

• There was limited evidence of the trust seeking the views of people who used the service.

The areas where the trust needs to make improvements are:

The trust must:

• Provide assurance that GPs are inducted into the service in a manner that helps to ensure patient safety.
• Implement a system that gives the trust oversight of safeguarding referrals made by GPs whilst working in out-of-hours and assurance that referrals are being shared with other agencies appropriately.

• Have in place a process that provides assurance that staff and GPs working in out-of-hours are made aware of patient safety alerts, MHRA alerts and updated NICE guidance.
• Ensure that only those staff who had received the appropriate training undertake chaperoning duties.
• Make improvements to ensure that patients are seen at both their place of residence and primary care centres in a timely manner.
• Ensure that issues highlighted at infection prevention and control audits are actioned and remedial action implemented in a timely manner.
• Engage with the public as a means of gathering views to improve the service provided.

In addition the trust should:

• Improve signage to the out-of-hours service at primary care centres.

• The trust should obtain assurances that where GPs and practitioners using their own equipment it is safe and fit for purpose.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice